Discussion:
Neisseria gonorrhea endocarditis is a rare complication of DGI and
represents 0.5 to 3% of such cases1. Although CIED
pocket infection has been reported in DGI13, to our
knowledge this is the first report of CIED associated gonococcal
endocarditis. Acute and subacute CIED infections are typically
attributed to coagulase negative Staphylococcus where as, chronic
infections are largely caused by S. Aureus (50%) and coagulase
negative staphylococci (50%) in more than 95% of
cases.2 Although rare, gonococcal endocarditis carries
high mortality and virulence, which highlights the importance of
awareness in the proper clinical context. Notably, initial blood
cultures are negative in 50% of disseminated gonococcal
infections.5
Cardiac involvement in DGI is associated with high morbidity and
mortality due to large vegetations, valvular destruction, electrical
instability due to conduction system involvement, and rarely myocarditis
which can be associated with malignant arrhythmias and sudden cardiac
death.6-8 Due to antibiotic resistance, large
vegetation size, and valvular destruction, gonococcal endocarditis is
often managed with surgical debulking and valve repair. However,
transvenous catheter based debulking may be a viable alternative in the
absence of valvular heart failure or in patients who are not surgical
candidates.
Over the last three decades there has been a significant increase in
cases of CIED associated endocarditis necessitating lead
extraction.9 When vegetations are > 2cm
in size, an open surgical approach is considered. Due to increasing
patient age and comorbidity, a number of these patients are not
candidates for surgical debulking and repair. Richardson et al. (8
patients) and Mirsa et al. (5 patients) have reported successful
thrombus/vegetation debulking (average size of 2 and 3 cm respectively,
subsequently decreased to <1cm and 2 cm) with the Penumbra
Aspiration System (Penumbra Inc, Alameda, CA) prior to CIED extraction.
Major complications of these case series included small septic emboli,
sepsis, and death unrelated to the procedure.10,11
This case illustrates the potential utility of catheter based vegetation
debulking prior to CIED extraction in a condition often treated
surgically. We employed joint decision making with our patient, who
chose the option of a wearable cardiac defibrillator and close follow-up
before possible CIED re-implantation.